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Involving and informing patients in decisions about their medical care is a very important issue since patients are one of the untapped resources in healthcare. But in low and middle income countries like China, where universal coverage of healthcare services has not been reached, a big concern is whether patients with equal needs can get equal access to health services under shared decision making processes.

In China, a fee-for-service mechanism has been well established during the past two decades. Although the current health system reform aims to provide universal coverage of essential healthcare to the general population, a large number of patients have to pay out of their own pockets, especially for services that use advanced technology or are very expensive. When involving patients in shared decision making for their healthcare, the first consideration for patients is the cost, i.e. which choice is the most affordable for them. There is a huge income gap between the poor and the rich. As stated by the World Bank recently, China’s Gini coefficient [a measure of statistical dispersion that is commonly used as a measure of inequality of income or wealth] hit 0.47 in 2009, and is expanding. The annual average income per headin 2008 was 15,781 Chinese yuan in urban areas and CNY4761 in rural areas (1USD=7CNY). Under these circumstances, a patient will be more likely to make a decision on the basis of cost, rather than on which option is most beneficial to their health.

Under the fee-for-service mechanism, it is also difficult for patients to receive unbiased information for decision making. Potentially biased information from doctors may unintentionally or intentionally lead patients to choose high cost health services. The mass media is full of market orientated advertisements for new diagnostic tools, medicines, and interventions. Patients face an overwhelming amount of information, which is mainly misleading. Inequity in access to comprehensive information will influence patients’ decisions about healthcare. Vulnerable populations such as poor and less educated people) may be more likely to become the victims of misleading information.

Also, under the fee-for-service mechanism there is increasing tension between patients and doctors. Patients may not trust their doctors, and they may have doubts that the information and recommendations from their doctor is correct, even if doctors have provided patients with the most comprehensive information to help their decision making.

From my point of view, therefore, it might be too early to involve patients in decision making in countries where universal healthcare coverage has not been available. However, patients could still be actively involved in the self-management of chronic diseases, such as diabetes and hypertension, and health intervention programmes as well.

Biao Xu, is a professor of epidemiology, School of Public Health, Fudan University, Shanghai, China.

In reference to the opinion of Biao Xu (1) who argued that it might be too early to involve patients in decision making in countries where universal healthcare coverage has not been available, we ascertain that in accordance with modern ethical, legal and deontological principles, physicians have an obligation to obtain the patient’s informed consent for the proposed diagnostic and therapeutic procedures (2,3,4). This obligation is imposed on the physicians by both the Oviedo Convention (5,6) and the World Health Organization (7,8). Its fulfilment cannot be reduced only to obtaining the patient’s signature (9)

The patient, expressing his informed consent to the proposed diagnostic or therapeutic procedures, participates (along with the doctor) in the decision-making process10 concerning his wellbeing. Many, even non-medical factors such as philosophy of life, religious beliefs,economic conditions, education level, social prejudices and preconceptions, may cause the patient to give or to refuse his consent. What is more, we are also aware that the level of healthcare in a given country has a significant impact on the availability of various forms oftreatment.

It is worth to note that there are significant differences, concerning healthcare standards, between different countries and regions of the world. However, we believe that neither the level of health protection nor other non-medical factors occurring in doctor-patient relationship should abolish or suspend the valid ethical principles including the patient’s right of to be informed and express his consent to medical procedures. It is a universal ethical imperative, which may cause all types of abuses when even temporally suspended.

Not obtaining informed consent from patients treated for various illnesses can be easily transferred to the reprehensible practice of not obtaining informed consent from medical trial participants (3,11)It should be also noted that social and cultural factors as part of the doctor-patient relationship, and tension between the respect for autonomy and beneficence exists. In Western societies, based on an individualistic philosophy, the respect for autonomy is by far more stressed than the principle of beneficence. However, in more collective societies, including those based on Confucian’s tradition such as China, the principle of respect for autonomy plays a minor role. We believe, however, that no matter what type of relationship is formedbetween doctor and patient, and regardless of the social and cultural conditions in which this relationship exists, the doctor’s irreducible obligation is to inform the patient about his health situation and to obtain his consent for conducting medical activities (12.)

4. National Commission for the Protection of Human Subjects of Biomedical andBehavioral Research. The Belmont report: ethical principles and guidelines for theprotection of human subjects of research. Washington, DC: Department of Health,Education and Welfare, 1979.

8. Council for International Organizations of Medical Sciences/World HealthOrganization. International ethical guidelines for biomedical research involvinghuman subjects. Geneva: World Health Organization, 2002.3